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Bhave S, Rodriguez V, Poterucha T, Mutasa S, Aberle D, Capaccione KM, Chen Y, Dsouza B, Dumeer S, Goldstein J, Hodes A, Leb J, Lungren M, Miller M, Monoky D, Navot B, Wattamwar K, Wattamwar A, Clerkin K, Ouyang D, Ashley E, Topkara VK, Maurer M, Einstein AJ, Uriel N, Homma S, Schwartz A, Jaramillo D, Perotte AJ, Elias P. Deep learning to detect left ventricular structural abnormalities in chest X-rays. Eur Heart J 2024:ehad782. [PMID: 38503537 DOI: 10.1093/eurheartj/ehad782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/24/2023] [Accepted: 11/14/2023] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND AIMS Early identification of cardiac structural abnormalities indicative of heart failure is crucial to improving patient outcomes. Chest X-rays (CXRs) are routinely conducted on a broad population of patients, presenting an opportunity to build scalable screening tools for structural abnormalities indicative of Stage B or worse heart failure with deep learning methods. In this study, a model was developed to identify severe left ventricular hypertrophy (SLVH) and dilated left ventricle (DLV) using CXRs. METHODS A total of 71 589 unique CXRs from 24 689 different patients completed within 1 year of echocardiograms were identified. Labels for SLVH, DLV, and a composite label indicating the presence of either were extracted from echocardiograms. A deep learning model was developed and evaluated using area under the receiver operating characteristic curve (AUROC). Performance was additionally validated on 8003 CXRs from an external site and compared against visual assessment by 15 board-certified radiologists. RESULTS The model yielded an AUROC of 0.79 (0.76-0.81) for SLVH, 0.80 (0.77-0.84) for DLV, and 0.80 (0.78-0.83) for the composite label, with similar performance on an external data set. The model outperformed all 15 individual radiologists for predicting the composite label and achieved a sensitivity of 71% vs. 66% against the consensus vote across all radiologists at a fixed specificity of 73%. CONCLUSIONS Deep learning analysis of CXRs can accurately detect the presence of certain structural abnormalities and may be useful in early identification of patients with LV hypertrophy and dilation. As a resource to promote further innovation, 71 589 CXRs with adjoining echocardiographic labels have been made publicly available.
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Affiliation(s)
- Shreyas Bhave
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Victor Rodriguez
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Timothy Poterucha
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Simukayi Mutasa
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Dwight Aberle
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Kathleen M Capaccione
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Yibo Chen
- Inova Fairfax Hospital Imaging Center, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Belinda Dsouza
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Shifali Dumeer
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Jonathan Goldstein
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Aaron Hodes
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Jay Leb
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Matthew Lungren
- Department of Radiology, University of California, SanFrancisco, CA, USA
| | - Mitchell Miller
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - David Monoky
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Benjamin Navot
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Kapil Wattamwar
- Division of Vascular and Interventional Radiology, Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
| | - Anoop Wattamwar
- Hackensack Radiology Group, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Kevin Clerkin
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - David Ouyang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Euan Ashley
- Stanford Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Veli K Topkara
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Mathew Maurer
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Andrew J Einstein
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Nir Uriel
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Shunichi Homma
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Allan Schwartz
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
| | - Diego Jaramillo
- Department of Radiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Adler J Perotte
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
| | - Pierre Elias
- Division of Cardiology and Department of Biomedical Informatics, Columbia University Irving Medical Center, 622 West 168th Street, PH20, NewYork, NY 10032, USA
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, 630 West 168th Street, NewYork, NY 10032, USA
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Miller T, Lang FM, Rahbari A, Theodoropoulos K, Topkara VK. Right heart failure after durable left ventricular assist device implantation. Expert Rev Med Devices 2024; 21:197-206. [PMID: 38214584 DOI: 10.1080/17434440.2024.2305362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Right heart failure (RHF) is a well-known complication after left ventricular assist device (LVAD) implantation and portends increased morbidity and mortality. Understanding the mechanisms and predictors of RHF in this clinical setting may offer ideas for early identification and aggressive management to minimize poor outcomes. A variety of medical therapies and mechanical circulatory support options are currently available for the management of post-LVAD RHF. AREAS COVERED We reviewed the existing definitions of RHF including its potential mechanisms in the context of durable LVAD implantation and currently available medical and device therapies. We performed a literature search using PubMed (from 2010 to 2023). EXPERT OPINION RHF remains a common complication after LVAD implantation. However, existing knowledge gaps limit clinicians' ability to adequately address its consequences. Early identification and management are crucial to reducing the risk of poor outcomes, but existing risk stratification tools perform poorly and have limited clinical applicability. This is an area ripe for investigation with the potential for major improvements in identification and targeted therapy in an effort to improve outcomes.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Frederick M Lang
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashkon Rahbari
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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3
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Oren D, Uriel M, Moeller CM, Valledor AF, DeFilippis EM, Lotan D, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Oh DKT, Bae D, Lin E, Theodoropoulos K, Naka Y, Takeda K, Choe J, Jennings DL, Majure D, Latif F, Sayer G, Uriel N. Utility of a fusion protein T-cell co-stimulation blocker Belatacept in heart transplant recipients: Real world experience from a high volume center. Clin Transplant 2024; 38:e15251. [PMID: 38504576 DOI: 10.1111/ctr.15251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Belatacept (BTC), a fusion protein, selectively inhibits T-cell co-stimulation by binding to the CD80 and CD86 receptors on antigen-presenting cells (APCs) and has been used as immunosuppression in adult renal transplant recipients. However, data regarding its use in heart transplant (HT) recipients are limited. This retrospective cohort study aimed to delineate BTC's application in HT, focusing on efficacy, safety, and associated complications at a high-volume HT center. METHODS A retrospective cohort study was conducted of patients who underwent HT between January 2017 and December 2021 and subsequently received BTC as part of their immunosuppressive regimen. Twenty-one HT recipients were identified. Baseline characteristics, history of rejection, and indication for BTC use were collected. Outcomes included renal function, graft function, allograft rejection and mortality. Follow-up data were collected through December 2023. RESULTS Among 776 patients monitored from January 2017 to December 2021 21 (2.7%) received BTC treatment. Average age at transplantation was 53 years (± 12 years), and 38% were women. BTC administration began, on average, 689 [483, 1830] days post-HT. The primary indications for BTC were elevated pre-formed donor-specific antibodies in highly sensitized patients (66.6%) and renal sparing (23.8%), in conjunction with reduced calcineurin inhibitor dosage. Only one (4.8%) patient encountered rejection within a year of starting BTC. Graft function by echocardiography remained stable at 6 and 12 months posttreatment. An improvement was observed in serum creatinine levels (76.2% of patients), decreasing from a median of 1.58 to 1.45 (IQR [1.0-2.1] to [1.1-1.9]) over 12 months (p = .054). eGFR improved at 3 and 6 months compared with 3 months pre- BTC levels; however, this was not statistically significant (p = .24). Treatment discontinuation occurred in seven patients (33.3%) of whom four (19%) were switched back to full dose CNI. Infections occurred in 11 patients (52.4%), leading to BTC discontinuation in 4 patients (19%). CONCLUSION In this cohort, BTC therapy was used as alternative immunosuppression for management of highly sensitized patients or for renal sparing. BTC therapy when combined with CNI dose reduction resulted in stabilization in renal function as measured through renal surrogate markers, which did not, however, reach statistical significance. Patients on BTC maintained a low rejection rate and preserved graft function. Infections were common during BTC therapy and were associated with medication pause/discontinuation in 19% of patients. Further randomized studies are needed to assess the efficacy and safety of BTC in HT recipients.
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Affiliation(s)
- Daniel Oren
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Matan Uriel
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Cathrine M Moeller
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Andrea Fernandez Valledor
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia M DeFilippis
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Dor Lotan
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Kevin J Clerkin
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Jayant K Raikhelkar
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Justin A Fried
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Kyung Taek Oh
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Bae
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Eddie Lin
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Kleanthis Theodoropoulos
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Jason Choe
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Douglas L Jennings
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - David Majure
- Division of Cardiology, Advanced Cardiac Care, Weill-Cornell Medical College, New York, New York, USA
| | - Farhana Latif
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Irving Medical Center, Columbia University, New York Presbyterian, New York, New York, USA
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4
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Oren D, Oh KT, Fried JA, Clerkin KJ, Raikhelkar JK, Topkara VK, Kaku Y, Takeda K, Naka Y, Burkhoff D, Latif F, Majure D, Colombo PC, Yuzefpolskaya M, Sayer GT, Uriel N. Hemodynamic Optimization by Invasive Ramp Test in Patients Supported With HeartMate 3 Left Ventricular Assist Device. ASAIO J 2024:00002480-990000000-00420. [PMID: 38373176 DOI: 10.1097/mat.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
In patients supported by the HeartMate 3 left ventricular assist device (HM3 LVAD), pump speed adjustments may improve hemodynamics. We investigated the hemodynamic implications of speed adjustments in HM3 recipients undergoing hemodynamic ramp tests. Clinically stable HM3 recipients who underwent routine invasive hemodynamic ramp tests between 2015 and 2022 at our center were included. Filling pressure optimization, defined as central venous pressure (CVP) <12 mm Hg and pulmonary capillary wedge pressure (PCWP) <18 mm Hg, was assessed at baseline and final pump speeds. Patients with optimized pressures were compared to nonoptimized patients. Overall 60 HM3 recipients with a median age of 62 years (56, 71) and time from LVAD implantation of 187 days (124, 476) were included. Optimized filling pressures were found in 35 patients (58%) at baseline speed. Speed was adjusted in 84% of the nonoptimized patients. Consequently, 39 patients (65%) had optimized pressures at final speed. There were no significant differences in hemodynamic findings between baseline and final speeds (p > 0.05 for all). Six and 12 month readmission-free rates were higher in optimized compared with nonoptimized patients (p = 0.03 for both), predominantly due to lower cardiac readmission-free rates (p = 0.052). In stable outpatients supported with HM3 who underwent routine ramp tests, optimized hemodynamics were achieved in only 2 of 3 of the patients. Patients with optimized pressures had lower all-cause readmission rates, primarily driven by fewer cardiac-related hospitalizations.
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Affiliation(s)
- Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sharon Slomovich
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Andrea Fernandez-Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kyung T Oh
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - David Majure
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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5
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Rubinstein G, Moeller CM, Lotan D, Slomovich S, Fernandez-Valledor A, Ranard LS, Leahy NE, Ladanyi A, Oren D, Clerkin KJ, Raikhelkar JK, Topkara VK, Fried JA, Vahl T, Colombo PC, Kaku Y, Takeda K, Naka Y, Yuzefpolskaya M, Sayer GT, Uriel N. The Hemodynamic Effects of Aortic Regurgitation in Patients Supported by a HeartMate 3 Left Ventricular Assist Device. J Card Fail 2024; 30:95-99. [PMID: 37625582 DOI: 10.1016/j.cardfail.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Aortic regurgitation (AR) is a common complication following left ventricular assist device (LVAD) implantation. We evaluated the hemodynamic implications of AR in patients with HeartMate 3 (HM3) LVAD at baseline and in response to speed changes. METHODS AND RESULTS Clinically stable outpatients supported by HM3 who underwent a routine hemodynamic ramp test were retrospectively enrolled in this analysis. Patients were stratified based on the presence of at least mild AR at baseline speed. Hemodynamic and echocardiographic parameters were compared between the AR and non-AR groups. Sixty-two patients were identified. At the baseline LVAD speed, 29 patients (47%) had AR, while 33 patients (53%) did not. Patients with AR were older and supported on HM3 for a longer duration. At baseline speed, all hemodynamic parameters were similar between the groups including central venous pressure, pulmonary capillary wedge pressure, pulmonary arterial pressures, cardiac output and index, and pulmonary artery pulsatility index (p > 0.05 for all). During the subacute assessment, AR worsened in some, but not all, patients, with increases in LVAD speed. There were no significant differences in 1-year mortality or hospitalization rates between the groups, however, at 1-year, ≥ moderate AR and right ventricular failure (RVF) were detected in higher rates among the AR group compared to the non-AR group (45% vs. 0%; p < 0.01, and 75% vs. 36.8%; p = 0.02, respectively). CONCLUSIONS In a cohort of stable outpatients supported with HM3 who underwent a routine hemodynamic ramp test, the presence of mild or greater AR did not impact the ability of HM3 LVADs to effectively unload the left ventricle during early subacute assessment. Although the presence of AR did not affect mortality and hospitalization rates, it resulted in higher rates of late hemodynamic-related events in the form of progressive AR and RVF.
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Affiliation(s)
- Gal Rubinstein
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York.
| | - Cathrine M Moeller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Dor Lotan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Sharon Slomovich
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | | | - Lauren S Ranard
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Nicole E Leahy
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Annamaria Ladanyi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Daniel Oren
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Jayant K Raikhelkar
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Justin A Fried
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Torsten Vahl
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York
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6
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Batra J, DeFilippis EM, Clerkin K, Bae D, Oh KT, Lotan D, Topkara VK, Lee SH, Latif F, Colombo P, Yuzefpolskaya M, Raikhelkar J, Majure DT, Sayer G, Uriel N. A change of heart: Characteristics and outcomes of multiple cardiac retransplant recipients. Clin Transplant 2024; 38:e15214. [PMID: 38078705 DOI: 10.1111/ctr.15214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/07/2023] [Accepted: 11/17/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Among heart transplant (HT) recipients who develop advanced graft dysfunction, cardiac re-transplantation may be considered. A smaller subset of patients will experience failure of their second allograft and undergo repeat re-transplantation. Outcomes among these individuals are not well-described. METHODS Adult and pediatric patients in the United Network for Organ Sharing (UNOS) registry who received HT between January 1, 1990 and December 31, 2020 were included. RESULTS Between 1990 and 2020, 90 individuals received a third HT and three underwent a fourth HT. Recipients were younger than those undergoing primary HT (mean age 32 years). Third HT was associated with significantly higher unadjusted rates of 1-year mortality (18% for third HT vs. 13% for second HT vs. 9% for primary HT, p < .001) and 10-year mortality (59% for third HT vs. 42% for second HT vs. 37% for primary HT, p < .001). Mortality was highest amongst recipients aged >60 years and those re-transplanted for acute graft failure. Long-term rates of CAV, rejection, chronic dialysis, and hospitalization for infection were also higher. CONCLUSIONS Third HT is associated with higher morbidity and mortality than primary HT. Further consensus is needed regarding appropriate organ stewardship for this unique subgroup.
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Affiliation(s)
- Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kevin Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - David Bae
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kyung Taek Oh
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Dor Lotan
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sun Hi Lee
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Paolo Colombo
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - David T Majure
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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7
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Kirschner M, Topkara VK, Sun J, Kurlansky P, Kaku Y, Naka Y, Yuzefpolskaya M, Colombo PC, Sayer G, Uriel N, Takeda K. Comparing 3-year survival and readmissions between HeartMate 3 and heart transplant as primary treatment for advanced heart failure. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01207-2. [PMID: 38154500 DOI: 10.1016/j.jtcvs.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE To compare 3-year survival and readmissions of patients who received the HeartMate 3 (HM3) left ventricular assist device (LVAD) or underwent orthotopic heart transplantation (OHT) as primary treatment for advanced heart failure. METHODS We retrospectively analyzed 381 adult patients who received an HM3 LVAD or were listed for OHT between January 2014 and March 2021 at our center. To minimize crossover bias, OHT recipients with a prior LVAD were excluded, and HM3 patients were censored at the time of transplant. Cohorts were propensity score-matched to reduce confounding variables. The primary outcome was 3-year survival, and the secondary outcome was mean cumulative all-cause unplanned readmission. RESULTS The study population comprised 185 HM3 patients (49%) and 196 OHT patients (51%), with 104 propensity score-matched patients in each group. After propensity score matching, there was no statistical difference in 3-year survival (83.7% for HM3 vs 87.0% for OHT; P = .91; relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.20). In the unmatched cohorts, patients age 18 to 49 years had comparable survival with HM3 and OHT (96.9% vs 95.9%; N = 91; P = 1.00; RR, 0.92; 95% CI, 0.09-9.78). Patients age 50+ years had slightly inferior survival with HM3 (75.0% vs 83.9%; N = 290; P = .60; RR, 1.51; 95% CI, 0.85-2.68). The mean number of readmissions at 3 years was higher in the HM3 group (3.89 vs 2.05; P < .001). CONCLUSIONS This exploratory analysis suggests that for similar patients, HM3 may provide comparable 3-year survival to OHT as a primary treatment for heart failure but may result in more readmissions.
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Affiliation(s)
- Michael Kirschner
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jocelyn Sun
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY; Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Yuji Kaku
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.
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Oren D, Moeller CM, Haythe JH, Rubinstein G, Fernandez Valledor A, Lotan D, Rosenblum H, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Naka Y, Takeda K, Latif F, Sayer G, Uriel N. Pumping for Two: Pregnancy in Patients Supported With a Left Ventricular Assist Device. ASAIO J 2023:00002480-990000000-00346. [PMID: 37934714 DOI: 10.1097/mat.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
This review discusses the challenges and outcomes associated with pregnancy during left ventricular assist device (LVAD) support. Women account for a third of the heart failure population in the United States. Left ventricular assist devices have emerged as a safe and effective treatment option for patients with advanced heart failure. Pregnancy during LVAD support can occur, and it presents significant risks to both mother and fetus, including hemodynamic stress, thrombotic events, medication-associated teratogenicity, and uterine impingement. This literature review identified 10 cases of confirmed pregnancy during LVAD support, of which eight resulted in successful births. Maternal and fetal mortality occurred in one case, and there was a spontaneous abortion in one case. The review highlights the importance of a multidisciplinary approach, promotion of shared decision-making, thoughtful anticoagulation, adjustment of LVAD speed, and medication optimization to maintain hemodynamic support during pregnancy. Hemodynamic changes during pregnancy include increased cardiac output, heart rate, and plasma volume, as well as decreased systemic vascular resistance, which can impact LVAD support. Despite reduced pulsatility in LVAD-supported patients, ovulation and reproductive capacity might be preserved, and viable pregnancies may be achieved with appropriate management. The review provides insights into the risks and considerations for a viable pregnancy during LVAD support, including the need for ongoing research to inform joined decision-making.
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Affiliation(s)
- Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Haythe
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrea Fernandez Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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9
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Harris E, Sewanan L, Topkara VK, Fried JA, Raikhelkar J, Colombo PC, Yuzefpolskaya M, DeFilippis EM, Latif F, Takeda K, Singh S, Uriel N, Sayer G, Clerkin KJ. New system, old problem: Increased wait time for high-priority transplant candidates. J Heart Lung Transplant 2023; 42:1497-1500. [PMID: 37506955 DOI: 10.1016/j.healun.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The 2018 heart allocation policy sought to improve risk stratification and reduce waitlist mortality for the sickest patients. This study sought to evaluate changes in wait times for the highest priority patients since policy implementation. All adult single-organ transplant recipients were identified in the United Network for Organ Sharing registry from October 18, 2018, to July 8, 2022, and separated into 4 periods. Outcomes were compared by blood type and UNOS region. Over the study period, 897 of 9,143 patients were listed as status 1 with no significant change in median wait time by blood type or region. More patients were listed as status 2 (4,523/9,143), and each subsequent period postpolicy change was associated with a 4.2-day increase in mean status 2 waitlist time (95% confidence interval 3.0-5.5, p < 0.0001). Wait times were longest for candidates with blood type O and shortest for AB & A. Regional variations continued, however, wait time increased in every region over time.
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Affiliation(s)
- Erin Harris
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Sewanan
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant Raikhelkar
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Ersilia M DeFilippis
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Farhana Latif
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Sameer Singh
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel Sayer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York.
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10
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Dardik G, Ning Y, Kurlansky P, Almodovar Cruz G, Vinogradsky A, Fried J, Topkara VK, Takeda K. Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support. Perfusion 2023:2676591231206524. [PMID: 37861303 DOI: 10.1177/02676591231206524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS). METHODS We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality. RESULTS Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality. CONCLUSIONS Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.
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Affiliation(s)
- Gabriel Dardik
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Alice Vinogradsky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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11
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Feng I, Wang AS, Takeda K, Topkara VK. Simultaneous heart-kidney transplant compared with heart transplant alone in patients with borderline renal function who are not dialysis dependent. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00960-1. [PMID: 37838336 DOI: 10.1016/j.jtcvs.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/11/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE This study assessed characteristics and outcomes of patients who are not dependent on dialysis receiving simultaneous heart kidney transplantation versus heart transplantation alone (HTA) to identify optimal eGFR threshold where combined transplant strategy may be superior. METHODS This study retrospectively analyzed 7896 adult patients with estimated glomerular filtration rate (eGFR) <60 mL/minute from the United Network for Organ Sharing database who received HTA or simultaneous heart kidney transplant between 2005 and 2021, excluding those who received pretransplant dialysis. Subjects were further stratified into 3 groups based on chronic kidney disease stage at time of transplant: Stage 3A (eGFR 45-59 mL/minute; n = 5044), Stage 3B (eGFR 30-44 mL/minute; n = 2193), and Stage 4 or 5 (eGFR <30 mL/minute; n = 659). Outcomes of interest were all-cause mortality, cardiac allograft failure, and freedom from chronic dialysis or renal transplant following heart transplant. RESULTS Simultaneous heart kidney transplant and HTA recipients differed in various baseline characteristics. Simultaneous heart kidney transplant recipients with eGFR <45 mL/minute had greater short- and long-term overall survival and cardiac allograft survival compared with HTA, as well as greater long-term freedom from chronic dialysis or renal transplant. These results were consistent with both propensity matched analyses and multivariable Cox regression analysis of 10 year outcomes. Optimal cutoff value for pretransplant eGFR in predicting elevated risk of renal failure in recipients of heart transplant alone was found to be eGFR ∼45 mL/minute. CONCLUSIONS Similar to patients with eGFR <30 mL/minute, patients with eGFR 30 to 44 mL/minute who underwent simultaneous heart kidney transplant had superior outcomes compared with HTA, suggesting possible benefit of combined transplant strategy for this subset of heart transplant candidates.
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Affiliation(s)
- Iris Feng
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Amy S Wang
- Division of General Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY.
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12
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Carey MR, Marshall D, Clerkin K, Laracuente R, Sanchez J, Jain SS, Raikhelkar JK, Leb JS, Kaku Y, Yuzefpolskaya M, Naka Y, Colombo PC, Sayer GT, Takeda K, Uriel N, Topkara VK, Fried JA. Aortic Root Thrombosis in patients with HeartMate 3 left ventricular assist device support. J Heart Lung Transplant 2023:S1053-2498(23)02007-7. [PMID: 37739242 DOI: 10.1016/j.healun.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 08/07/2023] [Accepted: 08/26/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Aortic root thrombosis(ART) is a complication of continuous-flow left ventricular assist device therapy. However, the incidence and related complications of ART in HeartMate 3 (HM3) patients remain unknown. METHODS Patients who underwent HM3 implantation from November 2014 to August 2020 at a quaternary academic medical center were included. Demographics and outcomes were abstracted from the medical record. Echocardiograms and contrast-enhanced computed tomography studies were reviewed to identify patients who developed ART and/or moderate or greater aortic insufficiency (AI) on HM3 support. RESULTS The study cohort included 197 HM3 patients with a median postimplant follow-up of 17.5 months. Nineteen patients (9.6%) developed ART during HM3 support, and 15 patients (7.6%) developed moderate or greater AI. Baseline age, gender, race, implantation strategy, and INTERMACS classification were similar between the ART and no-ART groups. ART was associated with an increased risk of death, stroke, or aortic valve (AV) intervention (subhazard ratio [SHR] 3.60 [95% confidence interval (CI) 1.71-7.56]; p = 0.001) and moderate or greater AI (SHR 11.1 [CI 3.60-34.1]; p < 0.001) but was not associated with a statistically significantly increased risk of death or stroke on HM3 support (2.12 [0.86-5.22]; p = 0.10). Of the 19 patients with ART, 6 (31.6%) developed moderate or greater AI, necessitating more frequent AV interventions (ART: 5 AV interventions [3 surgical repairs, 1 surgical replacement, 1 transcatheter replacement; 26.3%]; no-ART: 0). CONCLUSIONS Nearly 10% of HM3 patients developed ART during device support. ART was associated with increased risk of a composite end-point of death, stroke, or AV intervention as well as moderate or greater AI.
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Affiliation(s)
- Matthew R Carey
- Department of Internal Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Dylan Marshall
- Division of Cardiology, NewYork-Presbyterian/Weill Cornell Medical College, New York, New York
| | - Kevin Clerkin
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Ronald Laracuente
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph Sanchez
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jayant K Raikhelkar
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Jay S Leb
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Department of Radiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Justin A Fried
- Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York.
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13
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Feng I, Kurlansky PA, Ning Y, Sun J, Naka Y, Topkara VK, Latif F, Sayer G, Uriel NY, Takeda K. Do age and functional dependence affect outcomes of simultaneous heart-kidney transplantation? JTCVS Open 2023; 15:262-289. [PMID: 37808044 PMCID: PMC10556940 DOI: 10.1016/j.xjon.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/26/2023] [Accepted: 05/18/2023] [Indexed: 10/10/2023]
Abstract
Objective This study assessed characteristics and outcomes of younger (18-65) versus older (>65) recipients of simultaneous heart-kidney (SHK) transplantation with varying functional dependence. Methods This study retrospectively analyzed 1398 patients from the United Network for Organ Sharing database who received SHK between 2010 and 2021. Patients who were <18 year old, underwent transplant of additional organs simultaneously, or had previous heart transplant were excluded. The primary end point was all-cause mortality, and secondary end points included adverse events and cause of death. Outcomes were also evaluated by propensity score-matched comparison. Results The number of annual SHK transplantation in the United States has significantly increased among both age groups over the past 2 decades (P < .0001). After propensity score matching of recipients aged 18 to 65 years (n = 1162) versus age >65 years (n = 236), baseline characteristics were similar and well-balanced between the 2 cohorts. Between matched cohorts, older recipients did not have increased posttransplant mortality compared with younger recipients (90-day survival, P = .85; 7-year survival, P = .61). Multivariable Cox regression analysis found that age (hazard ratio [HR], 1.039 [0.975-1.106], P = .2415) and pretransplant functional status with interaction term for age (some assistance, HR, 0.965 [0.902-1.033], P = .3079; total assistance, HR, 0.976 [0.914-1.041], P = .4610) were not significant risk factors for 7-year post-SHK transplantation mortality. Conclusions Older and more functionally dependent recipients in this study did not have increased post-SHK transplantation mortality. These findings have important implications for organ allocation among elderly patients, as they support the need for thorough assessment of SHK candidates in terms of comorbidities, rather than exclusion solely based on age and functional dependence.
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Affiliation(s)
- Iris Feng
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paul A. Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
- Department of Surgery, Center of Innovation and Outcomes Research, Columbia University, New York, NY
| | - Yuming Ning
- Department of Surgery, Center of Innovation and Outcomes Research, Columbia University, New York, NY
| | - Jocelyn Sun
- Department of Surgery, Center of Innovation and Outcomes Research, Columbia University, New York, NY
| | - Yoshifumi Naka
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Y. Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
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14
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Stöhr EJ, Ji R, Mondellini G, Braghieri L, Akiyama K, Castagna F, Pinsino A, Cockcroft JR, Silverman RH, Trocio S, Zatvarska O, Konofagou E, Apostolakis I, Topkara VK, Takayama H, Takeda K, Naka Y, Uriel N, Yuzefpolskaya M, Willey JZ, McDonnell BJ, Colombo PC. Pulsatility and flow patterns across macro- and microcirculatory arteries of continuous-flow left ventricular assist device patients. J Heart Lung Transplant 2023; 42:1223-1232. [PMID: 37098374 PMCID: PMC11078160 DOI: 10.1016/j.healun.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Reduced arterial pulsatility in continuous-flow left ventricular assist devices (CF-LVAD) patients has been implicated in clinical complications. Consequently, recent improvements in clinical outcomes have been attributed to the "artificial pulse" technology inherent to the HeartMate3 (HM3) LVAD. However, the effect of the "artificial pulse" on arterial flow, transmission of pulsatility into the microcirculation and its association with LVAD pump parameters is not known. METHODS The local flow oscillation (pulsatility index, PI) of common carotid arteries (CCAs), middle cerebral arteries (MCAs) and central retinal arteries (CRAs-representing the microcirculation) were quantified by 2D-aligned, angle-corrected Doppler ultrasound in 148 participants: healthy controls, n = 32; heart failure (HF), n = 43; HeartMate II (HMII), n = 32; HM3, n = 41. RESULTS In HM3 patients, 2D-Doppler PI in beats with "artificial pulse" and beats with "continuous-flow" was similar to that of HMII patients across the macro- and microcirculation. Additionally, peak systolic velocity did not differ between HM3 and HMII patients. Transmission of PI into the microcirculation was higher in both HM3 (during the beats with "artificial pulse") and in HMII patients compared with HF patients. LVAD pump speed was inversely associated with microvascular PI in HMII and HM3 (HMII, r2 = 0.51, p < 0.0001; HM3 "continuous-flow," r2 = 0.32, p = 0.0009; HM3 "artificial pulse," r2 = 0.23, p = 0.007), while LVAD pump PI was only associated with microcirculatory PI in HMII patients. CONCLUSIONS The "artificial pulse" of the HM3 is detectable in the macro- and microcirculation but without creating a significant alteration in PI compared with HMII patients. Increased transmission of pulsatility and the association between pump speed and PI in the microcirculation indicate that the future clinical care of HM3 patients may involve individualized pump settings according to the microcirculatory PI in specific end-organs.
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Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, New York; Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Francesco Castagna
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiology Division, Montefiore Medical Center, New York, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald H Silverman
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York
| | - Samuel Trocio
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Oksana Zatvarska
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Iason Apostolakis
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Koji Takeda
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Yoshifumi Naka
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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15
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DeFilippis EM, Batra J, Donald E, Rubin G, Jou S, Razzaq A, Wan EY, Garan H, Takeda K, Sayer G, Uriel N, Topkara VK, Biviano A, Yarmohammadi H. Long-Term Outcomes of Permanent Pacemaker Implantation in Bicaval Heart Transplant Recipients. JACC Clin Electrophysiol 2023; 9:1964-1971. [PMID: 37480861 DOI: 10.1016/j.jacep.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Permanent pacemakers (PPMs) may be necessary in up to 10% of patients after heart transplantation (HT). OBJECTIVES The purpose of this study was to evaluate long-term outcomes and clinical courses of heart transplant recipients who received PPM. METHODS All patients who required PPM after bicaval HT at Columbia University between January 2005 and December 2021 were included. Cases were compared to matched heart transplant recipients by age, sex, and year of transplantation. Patient and device characteristics including complications and device interrogations were reviewed. Outcomes of re-transplantation or graft failure/death were compared between groups. RESULTS Of 1,082 heart transplant recipients, 41 (3.8%) received PPMs. The median time from transplantation to PPM was 118 days (IQR: 18-920 days). The most common indications were sinus node dysfunction (60%, n = 25) and atrioventricular (AV) nodal disease (41.5%, n = 17). Post-implantation complications included pocket hematoma (n = 3), lead under-sensing (n = 2), and pocket infection requiring explant (n = 1). Rates of death and re-transplantation at 10 years post-HT were similar between groups. In multivariable analysis, after adjustment for mechanical circulatory support, pretransplantation amiodarone use, donor ischemic time and age, only older donor age was associated with increased risk of PPM implantation (P = 0.03). There was a significant decrease in PPM placement after 2018 (1.2% vs 4.4%, P = 0.02), largely driven by a decline in early PPM placement. There were no differences in mortality or need for re-transplantation between groups. CONCLUSIONS PPMs are implanted after HT for sinus and atrioventricular node dysfunctions with low incidence of device-related complications. Our study shows a decrease in PPM implantation after 2018, likely attributable to expectant management in the early postoperative period.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elena Donald
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Geoffrey Rubin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Stephanie Jou
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ansa Razzaq
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Hasan Garan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Angelo Biviano
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Hirad Yarmohammadi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
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16
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Tao A, Raikhelkar J, Benvenuto L, Topkara VK, Brenner K, Fried J, Salako O, Colombo PC, Yuzefpolskaya M, Takeda K, Restaino S, Latif F, Uriel N, Sayer GT, Clerkin KJ. Impact of preheart transplant spirometry and DCLO measurement on post-transplant pulmonary outcomes. J Heart Lung Transplant 2023; 42:819-827. [PMID: 36806438 PMCID: PMC10192045 DOI: 10.1016/j.healun.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/06/2023] [Accepted: 01/18/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Pulmonary function tests (PFT) are a frequent component of heart transplant evaluation. In cardiac surgery abnormal PFTs, especially reduced DLCO, have been associated with poor outcomes. We sought to evaluate the impact of pretransplant PFTs on post-transplant pulmonary outcomes and patient survival. METHODS Among the 652 adult heart transplant recipients between January 1, 2010 and July 31, 2021, 462 had PFTs and constituted the patient cohort. Obstructive ventilatory defects (OVD), restrictive ventilatory defects (RVD), and reduced DLCO were defined according to established criteria. The primary outcome was the combined endpoint of a post-transplant pulmonary complication defined as reintubation, postoperative pneumonia, prolonged intubation, or tracheostomy. Secondary outcomes included 90-day all-cause mortality, length of stay, and the odds of individual pulmonary complications. Kaplan-Meier survival analysis, multivariable Cox proportional-hazards regression, and multivariable logistic regression were performed to compare outcomes between the groups. RESULTS Patients with severe OVD (OR 1.48, 95% CI 1.18-5.23, p = 0.02) or severely reduced DLCO (OR 1.95, 95% CI 1.19-3.20, p = 0.008) had increased odds of post-transplant pulmonary complications. Following multivariable adjustment, severe OVD (aOR 2.67, 95% CI 1.15-6.19, p = 0.02) and severely reduced DLCO (aOR 1.79, 95% CI 1.05-3.04) remained strongly associated with post-transplant pulmonary complications. Patients with any degree of extrinsic RVD, moderate or less OVD, or moderately reduced DLCO or less did not have increased odds of post-transplant pulmonary complications. Ninety-day post-transplant survival was significantly reduced for both severe OVD (97.2% vs 86.5%, p = 0.04) and severely reduced DLCO (97.3% vs 90.4%, p = 0.004). Post-transplant ICU and hospital length of stay were nominally longer for both groups as well. CONCLUSIONS Severe OVD or severely reduced DLCO on preheart transplant PFTs were associated with increased odds of post-transplant pulmonary complications and early mortality.
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Affiliation(s)
- Alice Tao
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Jayant Raikhelkar
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Luke Benvenuto
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Keith Brenner
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Justin Fried
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Oluwafeyijimi Salako
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Susan Restaino
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Farhana Latif
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York.
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17
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Miller T, Topkara VK. Mechanical circulatory support device selection for bridging to cardiac transplantation: a clinical guide. Expert Rev Med Devices 2023; 20:449-457. [PMID: 37086178 DOI: 10.1080/17434440.2023.2206562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Many patients listed for transplant require temporary or durable mechanical circulatory support (MCS) devices for bridging to cardiac transplantation. The choice of device for bridging to heart depends on a number of factors including level of support desired and patient-device hemocompatibility. AREAS COVERED The authors summarize the current heart transplant landscape including the new UNOS listing criteria as well as indications for bridging to transplant with MCS devices. The authors also review the characteristics of commonly used MCS devices and discuss the limited evidence supporting their use in cardiogenic shock and specifically as a bridge to heart transplant. EXPERT OPINION The new UNOS heart organ allocation policy has resulted in a growth in the use of temporary MCS devices as bridge to transplantation for patients with cardiogenic shock, while bridging with durable MCS devices have become more challenging. Patients supported on temporary MCS devices should be routinely assessed for potential of myocardial recovery prior to urgent transplantation. Emerging machine learning algorithms may help better identify individuals who are likely to recover on temporary or durable MCS therapy. Modifications to the current heart allocation policy may facilitate bridging of patients with durable left ventricular assist devices.
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Affiliation(s)
- Tamari Miller
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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18
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Liao X, Kennel PJ, Liu B, Nash TR, Zhuang RZ, Godier-Furnemont AF, Xue C, Lu R, Colombo PC, Uriel N, Reilly MP, Marx SO, Vunjak-Novakovic G, Topkara VK. Effect of mechanical unloading on genome-wide DNA methylation profile of the failing human heart. JCI Insight 2023; 8:161788. [PMID: 36656640 PMCID: PMC9977498 DOI: 10.1172/jci.insight.161788] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Heart failure (HF) is characterized by global alterations in myocardial DNA methylation, yet little is known about the epigenetic regulation of the noncoding genome and potential reversibility of DNA methylation with left ventricular assist device (LVAD) therapy. Genome-wide mapping of myocardial DNA methylation in 36 patients with HF at LVAD implantation, 8 patients at LVAD explantation, and 7 nonfailing (NF) donors using a high-density bead array platform identified 2,079 differentially methylated positions (DMPs) in ischemic cardiomyopathy (ICM) and 261 DMPs in nonischemic cardiomyopathy (NICM). LVAD support resulted in normalization of 3.2% of HF-associated DMPs. Methylation-expression correlation analysis yielded several protein-coding genes that are hypomethylated and upregulated (HTRA1, FBXO16, EFCAB13, and AKAP13) or hypermethylated and downregulated (TBX3) in HF. A potentially novel cardiac-specific super-enhancer long noncoding RNA (lncRNA) (LINC00881) is hypermethylated and downregulated in human HF. LINC00881 is an upstream regulator of sarcomere and calcium channel gene expression including MYH6, CACNA1C, and RYR2. LINC00881 knockdown reduces peak calcium amplitude in the beating human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). These data suggest that HF-associated changes in myocardial DNA methylation within coding and noncoding genomes are minimally reversible with mechanical unloading. Epigenetic reprogramming strategies may be necessary to achieve sustained clinical recovery from heart failure.
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Affiliation(s)
- Xianghai Liao
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Peter J Kennel
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Bohao Liu
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Trevor R Nash
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Richard Z Zhuang
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | | | - Chenyi Xue
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Rong Lu
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Muredach P Reilly
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | - Steven O Marx
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
| | | | - Veli K Topkara
- Division of Cardiology, Columbia University Irving Medical Center - New York Presbyterian, New York, New York, USA
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19
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Batra J, DeFilippis EM, Golob S, Lumish H, Clerkin K, Topkara VK, Restaino S, Lee SH, Latif F, Raikhelkar J, Fried J, Oh KT, Lin E, Colombo PC, Yuzefpolskaya M, Sayer G, Uriel N. Early post-transplant leukopenia in heart transplant recipients and its impact on outcomes. Clin Transplant 2023; 37:e14934. [PMID: 36798992 DOI: 10.1111/ctr.14934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/11/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Leukopenia in the early period following heart transplantation (HT) is not well-studied. The aim of this study was to evaluate risk factors for the development of post-transplant leukopenia and its consequences for HT recipients. METHODS Adult patients at a large-volume transplant center who received HT between January 1, 2010 and December 31, 2020 were included. The incidence of leukopenia (WBC ≤3 × 103 /μL) in the first 90-days following HT, individual risk factors, and its effect on 1-year outcomes were evaluated. RESULTS Of 506 HT recipients, 184 (36%) developed leukopenia within 90-days. Median duration of the first leukopenia episode was 15.5 days (IQR 8-42.5 days). Individuals who developed leukopenia had lower pre-transplant WBC counts compared to those who did not (6.1 × 103 /μL vs. 6.9 × 103 /μL, p = .02). Initial immunosuppressive and infectious chemoprophylactic regimens were not significantly different between groups. Early leukopenia was associated with a higher mortality at 1-year (6.6% vs. 2.1%, p = .008; adjusted HR 3.0) and an increased risk of recurrent episodes. Rates of infection and rejection were not significantly different between the two groups. CONCLUSIONS Leukopenia in the early period following HT is common and associated with an increased risk of mortality. Further study is needed to identify individuals at highest risk for leukopenia prior to transplant and optimize immunosuppressive and infectious chemoprophylactic regimens for this subgroup.
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Affiliation(s)
- Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Stephanie Golob
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Heidi Lumish
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kevin Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Susan Restaino
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sun Hi Lee
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kyung Taek Oh
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Edward Lin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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20
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Uriel MH, Clerkin KJ, Takeda K, Naka Y, Sayer GT, Uriel N, Topkara VK. Bridging to transplant with HeartMate 3 left ventricular assist devices in the new heart organ allocation system: An individualized approach. J Heart Lung Transplant 2023; 42:124-133. [PMID: 36272893 DOI: 10.1016/j.healun.2022.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/01/2022] [Accepted: 08/28/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Following the MOMENTUM 3 trial and the discontinuation of the HeartWare HVAD, the HeartMate 3 LVAD (HM 3) has become the main durable device for bridging to transplantation; however, outcome of this strategy in the new heart allocation system is not well understood. METHODS The United Network for Organ Sharing (UNOS) registry was queried to include adult patients (≥18 years old) listed for heart transplantation between 2010 and 2020. Trends in durable LVAD utilization and outcomes of patients with HM 3 LVAD were examined in the pre- vs post-heart allocation system. RESULTS From 2017 to 2020, there was a 28.3% decline in the number of patients waitlisted with an FDA-approved durable LVAD. Overall, 449 patients were waitlisted with HM 3 in the pre-allocation era compared to 1094 patients in the post-allocation. Cumulative incidence of heart transplantation (53.4% vs 50.7%, p = 0.76) and death or delisting for worsening status (5.0%, vs 4.2%, p = 0.43) at 1-year after listing with HM 3 LVAD was comparable in the pre- vs post-allocation era. Old age (>50), ischemic HF, poor functional status, elevated creatinine (>1.3 mg/dL), pulmonary hypertension (>3 WU), and obesity (body mass index > 33 kg/m2) were predictors of post-transplant graft mortality after bridging with HM 3. CONCLUSIONS While the utilization of durable devices as BTT have declined under the new heart allocation system, bridging with HM 3 LVAD remains a safe strategy in carefully selected patients. Bridging decision should be individualized based on patient risk factors.
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Affiliation(s)
- Matan H Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York; Division of Cardiothoracic Surgery, Department of Surgery, Weill Cornell Medical Center, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York.
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21
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Driggin E, Chung A, Concha D, Stanton L, Topkara VK, Maurer MS, Fried JA, Latif F, Takeda K, Sayer G, Uriel N, Clerkin KJ. The impact of pre-transplant weight loss on survival following cardiac transplantation. Clin Transplant 2022; 36:e14831. [PMID: 36271917 PMCID: PMC9984247 DOI: 10.1111/ctr.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/07/2022] [Accepted: 09/24/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Significant weight loss due to cardiac cachexia is an independent predictor of mortality in many heart failure (HF) clinical trials. The impact of significant weight loss while on the waitlist for heart transplant (HT) has yet to be studied with respect to post-transplant survival. METHODS Adult HT recipients from 2010 to 2021 were identified in the UNOS registry. Patients who experienced an absolute weight change from the time of listing to transplant were included and classified into two groups by percent weight loss from time of listing to time of transplant using a cut-off of 10%. The primary endpoint was 1-year survival following HT. RESULTS 5951 patients were included in the analysis, of whom 763 (13%) experienced ≥10% weight loss from the time of listing to transplant. Weight loss ≥ 10% was associated with reduced 1-year post-transplant survival (86.9% vs. 91.0%, long-rank p = .0003). Additionally, weight loss ≥ 10% was an independent predictor of 1-year mortality in a multivariable model adjusting for significant risk factors (adjusted HR 1.23, 95% CI 1.04-1.46). In secondary analyses, weight loss ≥ 10% was associated with reduced 1-year survival independent of hospitalized status at time of transplant as well as obesity status at listing (i.e., body mass index [BMI] < 30 kg/m2 and BMI ≥ 30 kg/m2 ). CONCLUSIONS Preoperative weight loss ≥ 10% is associated with reduced survival in patients listed for HT. Nutrition interventions prior to transplant may prove beneficial in this population.
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Affiliation(s)
- Elissa Driggin
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Alice Chung
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Daniella Concha
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Liam Stanton
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Veli K Topkara
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Mathew S Maurer
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Justin A Fried
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Farhana Latif
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Koji Takeda
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Gabriel Sayer
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Nir Uriel
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
| | - Kevin J Clerkin
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, Division of Cardiology, New York, New York, USA
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22
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Clerkin KJ, Topkara VK, Farr MA, Jain R, Colombo PC, Restaino S, Sayer G, Castillo M, Lam EY, Chernovolenko M, Yuzefpolskaya M, DeFilippis E, Latif F, Zorn E, Takeda K, Johnson LL, Uriel N, Einstein AJ. Noninvasive Physiologic Assessment of Cardiac Allograft Vasculopathy Is Prognostic for Post-Transplant Events. J Am Coll Cardiol 2022; 80:1617-1628. [PMID: 36265957 PMCID: PMC9758655 DOI: 10.1016/j.jacc.2022.08.751] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 08/10/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) causes impaired blood flow in both epicardial coronary arteries and the microvasculature. A leading cause of post-transplant mortality, CAV affects 50% of heart transplant recipients within 10 years of heart transplant. OBJECTIVES This analysis examined the outcomes of heart transplant recipients with reduced myocardial blood flow reserve (MBFR) and microvascular CAV detected by 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging. METHODS A total of 181 heart transplant recipients who underwent PET to assess for CAV were included with a median follow-up of 4.7 years. Patients were classified into 2 groups according to the total MBFR: >2.0 and ≤2.0. Microvascular CAV was defined as no epicardial CAV detected by PET and/or coronary angiography, but with an MBFR ≤2.0 by PET. RESULTS In total, 71 (39%) patients had an MBFR ≤2.0. Patients with an MBFR ≤2.0 experienced an increased risk for all outcomes: 7-fold increase in death or retransplantation (HR: 7.05; 95% CI: 3.2-15.6; P < 0.0001), 12-fold increase in cardiovascular death (HR: 12.0; 95% CI: 2.64-54.12; P = 0.001), and 10-fold increase in cardiovascular hospitalization (HR: 10.1; 95% CI: 3.43-29.9; P < 0.0001). The 5-year mean survival was 302 days less than those with an MBFR >2.0 (95% CI: 260.2-345.4 days; P < 0.0001). Microvascular CAV (adjusted HR: 3.86; 95% CI: 1.58-9.40; P = 0.003) was independently associated with an increased risk of death or retransplantation. CONCLUSIONS Abnormal myocardial blood flow reserve, even in the absence of epicardial CAV, identifies patients at a high risk of death or retransplantation. Measures of myocardial blood flow provide prognostic information in addition to traditional CAV assessment.
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Affiliation(s)
- Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/VeliKTopkaraMD
| | - Maryjane A Farr
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/MaryjaneFarrMD
| | - Rashmi Jain
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Restaino
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Michelle Castillo
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elaine Y Lam
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Margarita Chernovolenko
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia DeFilippis
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/ersied727
| | - Farhana Latif
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Emmanuel Zorn
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Lynne L Johnson
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/NirUrielMD
| | - Andrew J Einstein
- Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA. https://twitter.com/AndrewEinstein7
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Chiu L, Jairam MP, Chow R, Chiu N, Shen M, Alhassan A, Lo CH, Chen A, Kennel PJ, Poterucha TJ, Topkara VK. Erratum to 'Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure' The American Journal of Cardiology Volume 174, 1 July 2022, Pages 89-95. Am J Cardiol 2022; 180:173. [PMID: 36064260 DOI: 10.1016/j.amjcard.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Leonard Chiu
- Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Ronald Chow
- Temerity Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Chiu
- Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Max Shen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Adam Alhassan
- University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chun-Han Lo
- Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Austin Chen
- Columbia University, Vagelos College of Physicians and Surgeons, Columbia University, Department of Medicine, New York, NY
| | - Peter J Kennel
- New York Presbyterian Hospital/Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Timothy J Poterucha
- New York Presbyterian Hospital/Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Veli K Topkara
- New York Presbyterian Hospital/Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.
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24
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Tseliou E, Lavine KJ, Wever-Pinzon O, Topkara VK, Meyns B, Adachi I, Zimpfer D, Birks EJ, Burkhoff D, Drakos SG. Biology of myocardial recovery in advanced heart failure with long-term mechanical support. J Heart Lung Transplant 2022; 41:1309-1323. [PMID: 35965183 DOI: 10.1016/j.healun.2022.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022] Open
Abstract
Cardiac remodeling is an adaptive, compensatory biological process following an initial insult to the myocardium that gradually becomes maladaptive and causes clinical deterioration and chronic heart failure (HF). This biological process involves several pathophysiological adaptations at the genetic, molecular, cellular, and tissue levels. A growing body of clinical and translational investigations demonstrated that cardiac remodeling and chronic HF does not invariably result in a static, end-stage phenotype but can be at least partially reversed. One of the paradigms which shed some additional light on the breadth and limits of myocardial elasticity and plasticity is long term mechanical circulatory support (MCS) in advanced HF pediatric and adult patients. MCS by providing (a) ventricular mechanical unloading and (b) effective hemodynamic support to the periphery results in functional, structural, cellular and molecular changes, known as cardiac reverse remodeling. Herein, we analyze and synthesize the advances in our understanding of the biology of MCS-mediated reverse remodeling and myocardial recovery. The MCS investigational setting offers access to human tissue, providing an unparalleled opportunity in cardiovascular medicine to perform in-depth characterizations of myocardial biology and the associated molecular, cellular, and structural recovery signatures. These human tissue findings have triggered and effectively fueled a "bedside to bench and back" approach through a variety of knockout, inhibition or overexpression mechanistic investigations in vitro and in vivo using small animal models. These follow-up translational and basic science studies leveraging human tissue findings have unveiled mechanistic myocardial recovery pathways which are currently undergoing further testing for potential therapeutic drug development. Essentially, the field is advancing by extending the lessons learned from the MCS cardiac recovery investigational setting to develop therapies applicable to the greater, not end-stage, HF population. This review article focuses on the biological aspects of the MCS-mediated myocardial recovery and together with its companion review article, focused on the clinical aspects, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Eleni Tseliou
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Kory J Lavine
- Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart Meyns
- Department of Cardiology and Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, TX
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY; Cardiovascular Research Foundation (CRF), New York, NY
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT.
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25
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Defilippis EM, Truby LK, Clerkin KJ, Donald E, Sinnenberg L, Varshney AS, Cogswell R, Kittleson MM, Haythe JH, Givertz MM, Hsich EM, Agarwal R, Topkara VK, Farr M. Increased Opportunities for Transplantation for Women in the New Heart Allocation System. J Card Fail 2022; 28:1149-1157. [PMID: 35470056 PMCID: PMC10257979 DOI: 10.1016/j.cardfail.2022.03.354] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Historically, women have had less access to advanced heart failure therapies, including temporary and permanent mechanical circulatory support and heart transplantation (HT), with worse waitlist and post-transplant survival compared with men. This study evaluated for improvement in sex differences across all phases of HT in the 2018 allocation system. METHODS AND RESULTS The United Network for Organ Sharing registry was queried to identify adult patients (≥18 years) listed for HT from October 18, 2016, to October 17, 2018 (old allocation), and from October 18, 2018, to October 18, 2020 (new allocation). The outcomes of interest included waitlist survival, pretransplant use of temporary and durable mechanical circulatory support, rates of HT, and post-transplant survival. There were 15,629 patients who were listed for HT and included in this analysis; 7745 (2039 women, 26.3%) in the new and 7875 patients (2074 women, 26.3%) in the old allocation system. When compared with men in the new allocation system, women were more likely to have lower priority United Network for Organ Sharing status at time of transplant, and less likely to be supported by an intra-aortic balloon pump (27.1% vs 32.2%, P < .001), with no difference in the use of venoarterial extracorporeal membrane oxygenation (5.5% vs 6.3%, P = .28). Despite these findings, when transplantation was viewed in the context of risk for death or delisting, the cumulative incidence of transplant within 6 months of listing was higher in women than men in the new allocation system (62.4% vs 54.9%, P < .001) with no differences in post-transplant survival. When comparing women in the old with the new allocation system, the distance traveled for organ procurement was 187.5 ± 207.0 miles vs 272.8 ± 233.7 miles (P < .001). CONCLUSIONS Although the use of temporary mechanical circulatory support in women remains lower than in men in the new allocation system, more women are being transplanted with comparable waitlist and post-transplant outcomes as men. Broader sharing may be making its greatest impact on improving transplant opportunities for women.
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Affiliation(s)
- Ersilia M Defilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lauren K Truby
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Elena Donald
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lauren Sinnenberg
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anubodh S Varshney
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jennifer H Haythe
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Michael M Givertz
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eileen M Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richa Agarwal
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Maryjane Farr
- and the University of Texas Southwestern Medical Center, Dallas, Texas.
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26
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Chiu L, Jairam MP, Chow R, Chiu N, Shen M, Alhassan A, Lo CH, Chen A, Kennel PJ, Poterucha TJ, Topkara VK. Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure. Am J Cardiol 2022; 174:89-95. [PMID: 35504747 DOI: 10.1016/j.amjcard.2022.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 12/26/2022]
Abstract
Acute decompensated heart failure (ADHF) is a primary cause of older adults presenting to the emergency department with acute dyspnea. Point-of-care lung ultrasound (LUS) has shown comparable or superior diagnostic accuracy in comparison with a chest x-ray (CXR) in patients presenting with symptoms of ADHF. The systematic review and meta-analysis aimed to elucidate the sensitivity and specificity of LUS in comparison with CXR for diagnosing ADHF and summarize the rapidly growing body of evidence in this domain. A total of 5 databases were searched through February 18, 2021, to identify observational studies that reported on the use of LUS compared with CXR in diagnosing ADHF in patients presenting with shortness of breath. Meta-analysis was conducted on the sensitivities and specificities of each diagnostic method. A total of 8 studies reporting on 2,787 patients were included in this meta-analysis. For patients presenting with signs and symptoms of ADHF, LUS was found to be more sensitive than CXR (91.8% vs 76.5%) and more specific than CXR (92.3% vs 87.0%) for the detection of cardiogenic pulmonary edema. In conclusion, LUS is more sensitive and specific than CXR in detecting pulmonary edema. This highlights the importance of sonographic B-lines, along with the accurate interpretation of clinical data, in the diagnosis of ADHF. In addition to its convenience, reduced costs, and reduced radiation exposure, LUS should be considered an effective alternative to CXR for evaluating patients with dyspnea in the setting of ADHF.
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27
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Fried JA, Griffin JM, Masoumi A, Clerkin KJ, Witer LJ, Topkara VK, Karmpaliotis D, Rabbani L, Colombo PC, Yuzefpolskaya M, Takayama H, Naka Y, Kirtane AJ, Brodie D, Sayer G, Uriel N, Takeda K, Garan AR. Predictors of Survival and Ventricular Recovery Following Acute Myocardial Infarction Requiring Extracorporeal Membrane Oxygenation Therapy. ASAIO J 2022; 68:800-807. [PMID: 35380184 DOI: 10.1097/mat.0000000000001570] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction with cardiogenic shock (AMI-CS) is increasing, but the ability to predict favorable outcomes with support remains limited. We retrospectively reviewed all patients with AMI-CS supported with VA-ECMO between December 2008 and June 2018. One hundred twenty-six patients received VA-ECMO for AMI-CS during the study period; of these, 39 (31.0%) experienced ventricular recovery and were discharged while 87 (69.0%) did not recover, with 71 (56.3%) dying in the hospital and 16 (12.7%) surviving to discharge with either left ventricular assist device or heart transplant. TIMI 3 flow in culprit artery (OR, 4.01; 95% CI, 1.25-12.77; p = 0.02), serum lactate (OR, 0.89; 95% CI, 0.80-0.99; p = 0.04), and prompt revascularization (OR, 3.39; 95% CI, 1.18-9.81; p = 0.02) were independent predictors of ventricular recovery. Four variables emerged as independent predictors of in-hospital mortality and were used to create the AMI-ECMO Risk Score: age >70 years, creatinine >1.5 mg/dL, serum lactate > 4.0 mmol/L, and lack of TIMI 3 flow in culprit artery. In patients supported with VA-ECMO for AMI-CS, prompt, successful revascularization, and lower serum lactate were associated with ventricular recovery while younger age, lower serum lactate, and creatinine, and successful revascularization were associated with survival to discharge. The AMI-ECMO risk score is a simple tool that can help risk stratify patients with AMI-CS being considered for VA-ECMO support.
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Affiliation(s)
- Justin A Fried
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Jan M Griffin
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Amirali Masoumi
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Lucas J Witer
- Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Veli K Topkara
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Dimitri Karmpaliotis
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - LeRoy Rabbani
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Ajay J Kirtane
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary/Critical Care, Columbia University Medical Center, New York, New York
| | - Gabriel Sayer
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Nir Uriel
- From the Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - A Reshad Garan
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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28
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DeFilippis EM, Topkara VK, Kirtane AJ, Takeda K, Naka Y, Garan AR. Mechanical Circulatory Support for Right Ventricular Failure. Card Fail Rev 2022; 8:e14. [PMID: 35516793 PMCID: PMC9062706 DOI: 10.15420/cfr.2021.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, US
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29
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DeFilippis EM, Clerkin KJ, Givens RC, Kleet A, Rosenblum H, O'Connell DC, Topkara VK, Bijou R, Sayer G, Uriel N, Takeda K, Farr MA. Impact of socioeconomic deprivation on evaluation for heart transplantation at an urban academic medical center. Clin Transplant 2022; 36:e14652. [PMID: 35315535 DOI: 10.1111/ctr.14652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
Abstract
For patients with advanced heart failure, socioeconomic deprivation may impede referral for heart transplantation (HT). We examined the association of socioeconomic deprivation with listing among patients evaluated at our institution and compared this against the backdrop of our local community. We conducted a retrospective cohort study of patients evaluated for HT between January 2017 and December 2020. Patient demographics and clinical characteristics were recorded. Block group-level area deprivation index (ADI) decile was obtained at each patient's home address and Socioeconomic Status (SES) index was determined by patient zip code. In total, 400 evaluations were initiated; 1 international patient was excluded. Among this population, 111 (27.8%) were women, 219 (54.9%) were White, 94 (23.6%) Black, and 59 (14.8%) Hispanic. 248 (62.2%) patients were listed for transplant. Listed patients had significantly higher SES index and lower ADI compared to those who were not listed. However, after adjustment for clinical factors, ADI and SESi were not predictive of listing. Similarly, patient sex, race, and insurance did not influence the likelihood of listing for HT. Notably, the distribution of the referral cohort based on ADI deciles was not reflective of our center's catchment area, indicating opportunities for improving access to transplant for disadvantaged populations. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Kevin J Clerkin
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Raymond C Givens
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Cardiology, Emory University Medical Center, Atlanta, GA, USA
| | - Audrey Kleet
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Hannah Rosenblum
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Veli K Topkara
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Rachel Bijou
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Maryjane A Farr
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA.,Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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30
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Topkara VK, Sayer GT, Clerkin KJ, Wever-Pinzon O, Takeda K, Takayama H, Selzman CH, Naka Y, Burkhoff D, Stehlik J, Farr MA, Fang JC, Uriel N, Drakos SG. Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation. J Am Coll Cardiol 2022; 79:900-913. [PMID: 35241224 PMCID: PMC8928585 DOI: 10.1016/j.jacc.2021.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients. OBJECTIVES This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery. METHODS Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system. RESULTS A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05). CONCLUSIONS Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
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Affiliation(s)
- Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
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Truby LK, Farr M, Topkara VK. Critically appraising the 2018 United Network for Organ Sharing donor allocation policy: adding life boats or rearranging the deck chairs? Curr Opin Anaesthesiol 2022; 35:42-47. [PMID: 34772845 PMCID: PMC8765708 DOI: 10.1097/aco.0000000000001077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Due to the growing mismatch between donor supply and demand as well as unacceptably high transplant waitlist mortality, the heart organ allocation system was revised in October 2018. This review gives an overview of the changes in the new heart organ allocation system and its impact on heart transplant practice and outcomes in the United States. RECENT FINDINGS The 2018 heart allocation system offers a 6-tiered policy and therefore prioritizes the sickest patients on the transplant waitlist. Patients supported with temporary mechanical circulatory support devices are prioritized as Status 1 or Status 2, resulting in increased utilization of this strategy. Patients supported with durable left ventricular assist devices have been prioritized as Status 3 or 4, which has resulted in decreased utilization of this strategy. Broader geographic sharing in the new heart allocation system has resulted in prolonged donor ischemic times. Overall, the new heart allocation system has resulted in significantly lower candidate waitlist mortality, shorter waitlist times, and higher incidence of transplantation. SUMMARY The new United Network for Organ Sharing allocation policy confers significant advantages over the prior algorithm, allowing for decreased waitlist times and improved waitlist mortality without major impact on posttransplant survival.
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Affiliation(s)
- Lauren K. Truby
- Duke Molecular Physiology Institute, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Jain R, Habal MV, Clerkin KJ, Latif F, Restaino SW, Zorn E, Takeda K, Naka Y, Yuzefpolskaya M, Farr MA, Colombo PC, Sayer GT, Uriel N, Topkara VK. De Novo Human Leukocyte Antigen Allosensitization in Heartmate 3 Versus Heartmate II Left Ventricular Assist Device Recipients. ASAIO J 2022; 68:226-232. [PMID: 33883507 DOI: 10.1097/mat.0000000000001451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Left ventricular assist devices (LVADs) are associated with the development of antihuman leukocyte antigen (HLA) antibodies, which can create a challenge for future transplantation in these patients. The differential effects of Heartmate 3 (HM3) versus Heartmate II (HMII) on de novo HLA allosensitization remain unknown. Patients who underwent HMII or HM3 implantation and had no prior HLA antibodies by solid-phase assay (Luminex) testing were included in this study. Complement-dependent cytotoxicity (CDC) panel reactive antibody (PRA) levels and Luminex antibody profiles were followed until cardiac transplantation, device explantation, or death. Electronic medical records were reviewed to examine posttransplant outcomes. Thirty-eight HM3 and 34 HMII patients with complete data were followed for 1.5 ± 1.1 years on device support. HM3 and HMII groups had similar age at implant, female gender, ischemic heart failure etiology, bridge strategy at implant, as well as intraoperative and postoperative transfusion requirements. 39.5% of HM3 and 47.1% of HMII patients developed detectable HLA antibodies by Luminex testing (p = 0.516). Development of high-level (mean fluorescence intensity >10,000) antibodies was significantly lower in HM3 than HMII patients (5.3 vs. 20.6%, p = 0.049). CDC PRA testing showed fewer HM3 patients with a positive result (PRA > 0%) than HMII patients (39.4 vs. 70.0%, p = 0.015). Among transplanted patients, those who had developed de novo sensitization on LVAD support showed a trend toward incidence of moderate to severe grade rejection compared with unsensitized patients (23.8 vs. 4.8%, p = 0.078). HM3 is associated with lower risk of de novo HLA sensitization compared with HMII.
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Affiliation(s)
- Rashmi Jain
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Marlena V Habal
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Susan W Restaino
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Emmanuel Zorn
- Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Maryjane A Farr
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel T Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Batra J, DeFilippis EM, Golob S, Clerkin K, Topkara VK, Habal MV, Restaino S, Griffin J, Hi Lee S, Latif F, Farr MA, Sayer G, Raikelkar J, Uriel N. Impact of Pretransplant Malignancy on Heart Transplantation Outcomes: Contemporary United Network for Organ Sharing Analysis Amidst Evolving Cancer Therapies. Circ Heart Fail 2022; 15:e008968. [PMID: 35094567 DOI: 10.1161/circheartfailure.121.008968] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND An aging population and improved cancer survivorship have increased the number of individuals with treated malignancy who develop advanced heart failure. The benefits of heart transplantation (HT) in patients with a pretransplant malignancy (PTM) must be balanced against risks of posttransplant malignancy in the setting of immunosuppression. METHODS Adult patients in the United Network for Organ Sharing registry who received HT between January 1, 2010, and December 31, 2020 were included. Trends, patient characteristics, and posttransplant outcomes in HT recipients with PTM were evaluated. RESULTS From 2000 to 2020, the proportion of HT recipients with PTM increased from 3.2% to 8.2%. From 2010 to 2020, 2113 (7.7%) of 27 344 HT recipients had PTM. PTM was associated with higher rates of 1-year mortality after HT (11.9% versus 9.2%; adjusted hazard ratio, 1.25 [95% CI, 1.09-1.44], P=0.001), driven by increased mortality in patients with hematologic PTM (adjusted hazard ratio, 2.00 [95% CI, 1.61-2.48]; P<0.001). For recipients who survived the first year, 5-year survival was similar between patients with and without PTM. Rates of malignancy at 5-years posttransplant were higher in the PTM group (20.4% versus 13.1%; adjusted hazard ratio, 1.57 [95% CI, 1.38-1.79], P<0.001). CONCLUSIONS Prevalence of PTM in HT recipients nearly tripled over the past 2 decades. Patients with hematologic PTM were at increased risk of early mortality after HT. Patients with PTM were also at higher risk for posttransplant malignancy. Guidelines that reflect contemporary oncological care are needed to inform care of this heterogenous and expanding group of individuals.
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Affiliation(s)
- Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephanie Golob
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kevin Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Marlena V Habal
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Susan Restaino
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jan Griffin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sun Hi Lee
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jayant Raikelkar
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Clerkin KJ, Salako O, Fried JA, Griffin JM, Raikhelkar J, Jain R, Restaino S, Colombo PC, Takeda K, Farr MA, Sayer G, Uriel N, Topkara VK. Impact of Temporary Percutaneous Mechanical Circulatory Support Before Transplantation in the 2018 Heart Allocation System. JACC Heart Fail 2022; 10:12-23. [PMID: 34969492 PMCID: PMC8724562 DOI: 10.1016/j.jchf.2021.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This analysis sought to investigate the waitlist and post-transplant outcomes of individuals bridged to transplantation by using temporary percutaneous endovascular mechanical circulatory support (tMCS) through a status 2 designation (cardiogenic shock and exception). BACKGROUND The 2018 donor heart allocation policy change granted a status 2 designation to patients supported with tMCS. METHODS Adult patients in the United Network for Organ Sharing registry after October 18, 2018 who received a status 2 designation for tMCS were included and grouped by their status 2 criteria: cardiogenic shock with hemodynamic criteria (CS-HD), cardiogenic shock without hemodynamic criteria before tMCS (CS-woHD), and exception. Baseline characteristics, waitlist events (death and delisting), and post-transplant outcomes were compared. RESULTS A total of 2,279 patients met inclusion criteria: 68.6% (n = 1,564) with CS-HD, 3.2% (n = 73) with CS-woHD, and 28.2% (n = 642) with exceptions. A total of 64.2% of patients underwent heart transplantation within 14 days of status 2 listing or upgrade, and 1.9% died or were delisted for worsening clinical condition. Among the 35.8% who did not undergo transplantation following 14 days, only 2.8% went on to receive a left ventricular assist device (LVAD). The 30-day transplantation likelihood was similar among groups: 80.1% for the CS-HD group vs 79.7% for the exception group vs 73.3% for the CS-woHD group; P = 0.31. However, patients who met criteria for CS-woHD had 2.3-fold greater risk of death or delisting (95% CI: 1.10-4.75; P = 0.03) compared with CS-HD patients after multivariable adjustment. Pre-tMCS hemodynamics were not associated with adverse waitlist events. CONCLUSIONS The use of tMCS is an efficient, safe, and effective strategy as a bridge to transplantation; however, patients with CS-woHD may represent a high-risk cohort. Transition to a durable LVAD was a rare event in this group.
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Affiliation(s)
- Kevin J. Clerkin
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Oluwafeyijimi Salako
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Justin A. Fried
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jan M. Griffin
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jayant Raikhelkar
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Rashmi Jain
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Susan Restaino
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Paolo C. Colombo
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Maryjane A. Farr
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Gabriel Sayer
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Nir Uriel
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Veli K Topkara
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Topkara VK, Elias P, Jain R, Sayer G, Burkhoff D, Uriel N. Machine Learning-Based Prediction of Myocardial Recovery in Patients With Left Ventricular Assist Device Support. Circ Heart Fail 2022; 15:e008711. [PMID: 34949101 PMCID: PMC8766904 DOI: 10.1161/circheartfailure.121.008711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prospective studies demonstrate that aggressive pharmacological therapy combined with pump speed optimization may result in myocardial recovery in larger numbers of patients supported with left ventricular assist device (LVAD). This study sought to determine whether the use of machine learning (ML) based models predict LVAD patients with myocardial recovery resulting in pump explant. METHODS A total of 20 270 adult patients with a durable continuous-flow LVAD in the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) were included in the study. Ninety-eight raw clinical variables were screened using the least absolute shrinkage and selection operator for selection of features associated with LVAD-induced myocardial recovery. ML models were developed in the training data set (70%) and were assessed in the validation data set (30%) by receiver operating curve and Kaplan-Meier analysis. RESULTS Least absolute shrinkage and selection operator identified 28 unique clinical features associated with LVAD-induced myocardial recovery, including age, cause of heart failure, psychosocial risk factors, laboratory values, cardiac rate and rhythm, and echocardiographic indices. ML models achieved area under the receiver operating curve of 0.813 to 0.824 in the validation data set outperforming logistic regression-based new INTERMACS recovery risk score (area under the receiver operating curve of 0.796) and previously established LVAD recovery risk scores (INTERMACS Cardiac Recovery Score and INTERMACS Recovery Score by Topkara et al) with area under the receiver operating curve of 0.744 and 0.748 (P<0.05). Patients who were predicted to recover by ML models demonstrated a significantly higher incidence of myocardial recovery resulting in LVAD explant in the validation cohort compared with those who were not predicted to recover (18.8% versus 2.6% at 4 years of pump support). CONCLUSIONS ML can be a valuable tool to identify subsets of LVAD patients who may be more likely to respond to myocardial recovery protocols.
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Affiliation(s)
- Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Pierre Elias
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Rashmi Jain
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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Clerkin KJ, Griffin JM, Fried JA, Raikhelkar J, Jain R, Topkara VK, Habal MV, Latif F, Restaino S, Colombo PC, Takeda K, Naka Y, Farr MA, Sayer G, Uriel N. How can we better inform our patients about post-heart transplantation survival? A conditional survival analysis. Clin Transplant 2021; 35:e14449. [PMID: 34363421 PMCID: PMC8697356 DOI: 10.1111/ctr.14449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Conditional survival (CS) is a dynamic method of survival analysis that provides an estimate of how an individual's future survival probability changes based on time post-transplant, individual characteristics, and post-transplant events. This study sought to provide post-transplant CS probabilities for heart transplant recipients based on different prognostic variables and provide a discussion tool for the providers and the patients. METHODS Adult heart transplant recipients from January 1, 2004, through October 18, 2018, were identified in the UNOS registry. CS probabilities were calculated using data from Kaplan-Meier survival estimates. RESULTS CS probability exceeded actuarial survival probability at all times post-transplant. Women had similar short-term, but greater long-term CS than men at all times post-transplant (10-year CS 1.8-11.5% greater [95% CI 1.2-12.9]). Patients with ECMO or a surgical BiVAD had decreased survival at the time of transplant, but their CS was indistinguishable from all others by 1-year post-transplant. Rejection and infection requiring hospitalization during the first year were associated with a persistently decreased CS probability. CONCLUSIONS In this study, we report differential conditional survival outcomes based on time, patient characteristics, and clinical events post-transplant, providing a dynamic assessment of survival. The survival probabilities will better inform patients and clinicians of future outcomes.
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Affiliation(s)
- Kevin J Clerkin
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jan M Griffin
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Justin A Fried
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jayant Raikhelkar
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Rashmi Jain
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Veli K Topkara
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Marlena V Habal
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Farhana Latif
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Susan Restaino
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Maryjane A Farr
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Milstein Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Rubin G, DeFilippis EM, Farr MA, Topkara VK, Yarmohammadi H. Implantable Cardioverter-Defibrillator Use After Heart Transplantation: A Gray Area for Primary Prevention. JACC Clin Electrophysiol 2021; 7:1314-1315. [PMID: 34600849 DOI: 10.1016/j.jacep.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/26/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
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38
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Grubb CS, Truby LK, Topkara VK, Bohnen MS, Yuzefpolskaya M, DeFilippis EM, Kleet A, Nakagawa S, Haythe JH, Axsom K, Colombo P, Takeda K, Uriel N, Sayer G, Garan H, Naka Y, Farr M. Advanced heart failure patients supported with ambulatory inotropic therapy: What defines success of therapy? Am Heart J 2021; 239:11-18. [PMID: 33984317 DOI: 10.1016/j.ahj.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to describe the profiles and outcomes of a cohort of advanced heart failure patients on ambulatory inotropic therapy (AIT). BACKGROUND With the growing burden of patients with end-stage heart failure, AIT is an increasingly common short or long-term option, for use as bridge to heart transplant (BTT), bridge to ventricular assist device (BTVAD), bridge to decision regarding advanced therapies (BTD) or as palliative care. AIT may be preferred by some patients and physicians to facilitate hospital discharge. However, counseling patients on risks and benefits is critically important in the modern era of defibrillators, durable mechanical support and palliative care. METHODS We retrospectively studied a cohort of 241 patients on AIT. End points included transplant, VAD implantation, weaning of inotropes, or death. The primary outcomes were survival on AIT and ability to reach intended goal if planned as BTT or BTVAD. We also evaluated recurrent heart failure hospitalizations, incidence of ventricular arrhythmias (VT/VF) and indwelling line infections. Unintended consequences of AIT, such reaching unintended end point (e.g. VAD implantation in BTT patient) or worse than expected outcome after LVAD or HT, were recorded. RESULTS Mean age of the cohort was 60.7 ± 13.2 years, 71% male, with Class III-IV heart failure (56% non-ischemic). Average ejection fraction was 19.4 ± 10.2%, pre-AIT cardiac index was 1.5 ± 0.4 L/min/m2 and 24% had prior ventricular arrhythmias. Overall on-AIT 1-year survival was 83%. Hospitalizations occurred in 51.9% (125) of patients a total of 174 times for worsening heart failure, line complication or ventricular arrhythmia. In the BTT cohort, only 42% were transplanted by the end of follow-up, with a 14.8% risk of death or delisting for clinical deterioration. For the patients who were transplanted, 1-year post HT survival was 96.7%. In the BTVAD cohort, 1-year survival after LVAD was 90%, but with 61.7% of patients undergoing LVAD as INTERMACS 1-2. In the palliative care cohort, only 24.5% of patients had a formal palliative care consult prior to AIT. CONCLUSIONS AIT is a strategy to discharge advanced heart failure patients from the hospital. It may be useful as bridge to transplant or ventricular assist device, but may be limited by complications such as hospitalizations, infections, and ventricular arrhythmias. Of particular note, it appears more challenging to bridge to transplant on AIT in the new allocation system. It is important to clarify the goals of AIT therapy upfront and continue to counsel patients on risks and benefits of the therapy itself and potential unintended consequences. Formalized, multi-disciplinary care planning is essential to clearly define individualized patient, as well as programmatic goals of AIT.
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Affiliation(s)
- Christopher S Grubb
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Lauren K Truby
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Michael S Bohnen
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | | | | | - Audrey Kleet
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Shunichi Nakagawa
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Haythe
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kelly Axsom
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo Colombo
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hasan Garan
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Maryjane Farr
- Department of Medicine, Columbia University Irving Medical Center, New York, NY.
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Bravo CA, Fried JA, Willey JZ, Javaid A, Mondellini GM, Braghieri L, Lumish H, Topkara VK, Kaku Y, Witer L, Takayama H, Takeda K, Sayer G, Uriel N, Demmer RT, Naka Y, Yuzefpolskaya M, Colombo PC. Presence of Intracardiac Thrombus at the Time of Left Ventricular Assist Device Implantation Is Associated With an Increased Risk of Stroke and Death. J Card Fail 2021; 27:1367-1373. [PMID: 34161806 DOI: 10.1016/j.cardfail.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Heart failure predisposes to intracardiac thrombus (ICT) formation. There are limited data on the prevalence and impact of preexisting ICT on postoperative outcomes in left ventricular assist device patients. We examined the risk for stroke and death in this patient population. METHODS AND RESULTS We retrospectively studied patients who were implanted with HeartMate (HM) II or HM3 between February 2009 and March 2019. Preoperative transthoracic echocardiograms, intraoperative transesophageal echocardiograms and operative reports were reviewed to identify ICT. There were 525 patients with a left ventricular assist device (median age 60.6 years, 81.8% male, 372 HMII and 151 HM3) included in this analysis. An ICT was identified in 44 patients (8.4%). During the follow-up, 43 patients experienced a stroke and 55 died. After multivariable adjustment, presence of ICT increased the risk for the composite of stroke or death at 6-month (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.00-3.33, P = .049). Patients with ICT were also at higher risk for stroke (HR 2.45, 95% CI 1.14-5.28, P = .021) and death (HR 2.36, 95% CI 1.17-4.79 P = .016) at 6 months of follow-up. CONCLUSIONS The presence of ICT is an independent predictor of stroke and death at 6 months after left ventricular assist device implantation. Additional studies are needed to help risk stratify and optimize the perioperative management of this patient population.
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Affiliation(s)
- Claudio A Bravo
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York; Department of Medicine, Division of Cardiology, University of Washington, Washington
| | - Justin A Fried
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Joshua Z Willey
- Department of Neurology, Columbia University, New York, New York
| | - Azka Javaid
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Giulio M Mondellini
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Heidi Lumish
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Yuji Kaku
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York
| | - Lucas Witer
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Ryan T Demmer
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York; Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiac Surgery, Columbia University, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York.
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Topkara VK, Clerkin KJ, Fried JA, Griffin J, Raikhelkar J, Hi Lee S, Latif F, Habal M, Horn E, Farr MA, Takada K, Naka Y, Jorde UP, Sayer G, Uriel N. Exception Status Listing in the New Adult Heart Allocation System: A New Solution to an Old Problem? Circ Heart Fail 2021; 14:e007916. [PMID: 34044577 DOI: 10.1161/circheartfailure.120.007916] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND One of the goals of the revised 6-tiered US adult heart allocation policy was to improve risk stratification of patients to lower exception status utilization for transplant listing. We sought to define the characteristics and outcomes of waitlisted patients using exception status and to examine region- and center-level differences in utilization of exception status in the new heart allocation system. METHODS This retrospective cohort analysis of the United Network for Organ Sharing database included adult waitlisted patients for heart transplant between October 18, 2018, and June 30, 2020, in the United States, stratified by use of exception status versus standard criteria. RESULTS Out of 6351 patients, 1907 (30.0%) were waitlisted under exception status. Patients using exception status were more likely to have a nonischemic cause of heart failure, blood type O, United Network for Organ Sharing status 2 at listing and were less likely to have a durable left ventricular assist device at listing. Exception status utilization varied significantly between and within United Network for Organ Sharing regions. Listing by exception criteria was associated with a significantly higher incidence of heart transplantation compared with listing by standard criteria (hazard ratio, 1.25 [1.15-1.38], P<0.001), without increased risk of death or delisting for worsening clinical status (hazard ratio, 0.83 [0.65-1.05], P=0.12) after multivariable adjustment. CONCLUSIONS The status tiers of the new heart allocation system may not fully capture medical urgency and complexity of waitlisted patients as assessed by transplant physicians and review committees and may limit the ability to develop a heart allocation score.
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Affiliation(s)
- Veli K Topkara
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Justin A Fried
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Jan Griffin
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Jayant Raikhelkar
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Sun Hi Lee
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Marlena Habal
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Evelyn Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (E.H., G.S., N.U.)
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY
| | - Koji Takada
- Division of Cardiac, Thoracic, Vascular Surgery, Department of Surgery (K.T., Y.N.), Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, Vascular Surgery, Department of Surgery (K.T., Y.N.), Columbia University Irving Medical Center, New York, NY
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY (U.P.J.)
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine (V.K.T., K.J.C., J.A.F., J.G., J.R., S.H.L., F.L., M.H., M.A.F., G.S., N.U.), Columbia University Irving Medical Center, New York, NY.,Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (E.H., G.S., N.U.)
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (E.H., G.S., N.U.)
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Stöhr EJ, Ji R, Akiyama K, Mondellini G, Braghieri L, Pinsino A, Cockcroft JR, Yuzefpolskaya M, Amlani A, Topkara VK, Takayama H, Naka Y, Uriel N, Takeda K, Colombo PC, McDonnell BJ, Willey JZ. Cerebral vasoreactivity in HeartMate 3 patients. J Heart Lung Transplant 2021; 40:786-793. [PMID: 34134913 DOI: 10.1016/j.healun.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND While rates of stroke have declined with the HeartMate3 (HM3) continuous- flow (CF) left ventricular assist device (LVAD), the impact of non-pulsatile flow and artificial pulse physiology on cerebrovascular function is not known. We hypothesized that improved hemodynamics and artificial pulse physiology of HM3 patients would augment cerebrovascular metabolic reactivity (CVR) compared with HeartMate II (HMII) CF-LVAD and heart failure (HF) patients. METHODS Mean, peak systolic and diastolic flow velocities (MFV, PSV, MinFV, respectively) and cerebral pulsatility index were determined in the middle cerebral artery (MCA) before and after a 30 sec breath-hold challenge in 90 participants: 24 healthy controls; 30 HF, 15 HMII, and 21 HM3 patients. RESULTS In HM3 patients, breath-holding increased MFV (Δ8 ± 10 cm/sec, p < .0001 vs baseline) to levels similar to HF patients (Δ9 ± 8 cm/sec, p > .05), higher than HMII patients (Δ2 ± 8 cm/sec, p < .01) but lower than healthy controls (Δ13 ± 7 cm/sec, p < .05). CF-LVAD altered the proportion of systolic and diastolic flow responses as reflected by a differential cerebral pulsatility index (p = .03). Baseline MFV was not related to CVR (r2 = 0.0008, p = .81). However, CF-LVAD pump speed was strongly inversely associated with CVR in HM II (r2 = 0.51, p = .003) but not HM3 patients (r2 = 0.01, p = .65). CONCLUSIONS Compared with HMII, HM3 patients have a significantly improved CVR. However, CVR remains lower in HM3 and HF patients than in healthy controls, therefore suggesting that changes in cerebral hemodynamics are not reversed by CF-LVAD therapy. Further research on the mechanisms and the long-term impact of altered cerebral hemodynamics in this unique patient population are warranted.
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Affiliation(s)
- Eric J Stöhr
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York.
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koichi Akiyama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York; Department of Anesthesia, Yodogawa Christian Hospital, Osaka City, Osaka, Japan
| | - Giulio Mondellini
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - John R Cockcroft
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Amrin Amlani
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Hiroo Takayama
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Yoshifumi Naka
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Koji Takeda
- Department of Medicine, Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York City, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York City, New York
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Abstract
This review provides a comprehensive overview of the past 25+ years of research into the development of left ventricular assist device (LVAD) to improve clinical outcomes in patients with severe end-stage heart failure and basic insights gained into the biology of heart failure gleaned from studies of hearts and myocardium of patients undergoing LVAD support. Clinical aspects of contemporary LVAD therapy, including evolving device technology, overall mortality, and complications, are reviewed. We explain the hemodynamic effects of LVAD support and how these lead to ventricular unloading. This includes a detailed review of the structural, cellular, and molecular aspects of LVAD-associated reverse remodeling. Synergisms between LVAD support and medical therapies for heart failure related to reverse remodeling, remission, and recovery are discussed within the context of both clinical outcomes and fundamental effects on myocardial biology. The incidence, clinical implications and factors most likely to be associated with improved ventricular function and remission of the heart failure are reviewed. Finally, we discuss recognized impediments to achieving myocardial recovery in the vast majority of LVAD-supported hearts and their implications for future research aimed at improving the overall rates of recovery.
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Affiliation(s)
| | | | - Gabriel Sayer
- Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Nir Uriel
- Cardiovascular Research Foundation, New York, NY (D.B.)
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Jennings DL, Truby LK, Littlefield AJ, Ciolek AM, Marshall D, Jain R, Topkara VK. Impact of heart failure drug therapy on rates of gastrointestinal bleeding in LVAD recipients: An INTERMACS analysis. Int J Artif Organs 2021; 44:965-971. [PMID: 33977770 DOI: 10.1177/03913988211013366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gastrointestinal bleeding (GIB) remains a common and vexing complication of left ventricular assist device (LVAD) support. Recent single-center analyses suggest that ACE inhibitors (ACEi)/angiotensin receptor blockers (ARB) and digoxin may prevent GIB in LVAD patients. Here we evaluate the effect of guideline-directed medical therapies (GDMT) for heart failure (HF) on rates of GIB through analysis of the INTERMACS registry database. METHODS Thirteen thousand seven hundred thirty-two patients who received a continuous-flow LVAD and were on antiplatelet therapy and anticoagulation with warfarin after 3 months of pump support were included in the analysis. GIB events following implant were assessed based on receipt of ACEi/ARB, beta-blockers (BB), mineralocorticoid receptor antagonist (MRA), amiodarone, digoxin, loop diuretics, and phosphiesterase-5 inhibitors (PDE5). Backwards stepwise cox regression was used to control for confounding of each drug class on each other, as well as for clinical variables like age, gender, renal function, HF etiology, and device strategy. RESULTS After 3 months of pump support medications used in LVAD patients were BB (65.0%), ACEi/ARB (51.7%), Amio (43.7%), MRA (37.9%), and loop diuretics (70.1%). In patients with available data, PDE and digoxin use were 18.2% and 16.9%, respectively. The overall incidence of GIB was 19.5% at 2 years of support. After adjustment for other clinical variables, loop diuretics (HR 1.274, p < 0.001) and PDE5 (HR 1.241, p < 0.001) use were associated with increased risk of GIB, while use of BB (HR 0.871, p = 0.006) was associated with lower risk of GIB. ACEi/ARB (HR 1.002, p = 0.971), Amio (HR 1.083, p = 0.106), AA (HR 0.967, p = 0.522) or digoxin (HR 1.087, p = 0.169) did not affect GIB rates on LVAD support (Figure). CONCLUSION Despite recent reports, ACEi/ARB, MRA, Amio, and digoxin use does not appear to be associated with GIB during LVAD support. The heightened risk seen in those on loop diuretics may reflect venous congestion in these patients, while antiplatelet effects of PDE5 could drive the higher risk of GIB.
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Affiliation(s)
- Douglas L Jennings
- Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY, USA.,Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Audrey J Littlefield
- Department of Pharmacy, NewYork-Presbyterian Hospital Weill Cornell Medical Center, New York, NY, USA
| | - Alana M Ciolek
- Department of Pharmacy, NewYork-Presbyterian Hospital Columbia University Irving Medical Center, New York, NY, USA
| | - Dylan Marshall
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Rashmi Jain
- Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, NY, USA
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Jain SS, Clerkin KJ, Roth ZB, Fried JA, Raikhelkar J, Griffin JM, Colombo PC, Yuzefpolskaya M, Latif F, Topkara VK, Farr MA, Naka Y, Takeda K, Sayer G, Uriel N. IMPACT OF PREOPERATIVE LYMPHOPENIA ON OUTCOMES AFTER HEART TRANSPLANT. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02000-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Marshall D, Sanchez J, Yuzefpolskaya M, Sayer GT, Takeda K, Naka Y, Colombo PC, Uriel N, Topkara VK. Safety of reduced anti-thrombotic strategy in patients with HeartMate 3 left ventricular assist device. J Heart Lung Transplant 2021; 40:237-240. [PMID: 33551226 DOI: 10.1016/j.healun.2021.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 11/19/2022] Open
Abstract
There are limited safety data on reduced anti-thrombotic therapy (RT) in patients with HeartMate 3 (HM3) left ventricular assist device (LVAD). We conducted a single-center, retrospective study of patients with HM3 managed with RT from November 2014 through January 2020. We analyzed baseline characteristics, RT indications, and bleeding and thrombotic complications. We found that 50 of 161 patients with HM3 (31.1%) received RT starting at a median time of 90.5 days after LVAD implantation. Patients on RT were older and more likely to have ischemic heart failure than patients on standard anti-thrombotic therapy (ST). The most common indication for RT was gastrointestinal bleeding (29 patients [58.0%]). At 1-year follow-up, 5.0% of patients on RT developed a thrombotic event. Switching patients from ST to RT reduced the occurrence of major bleeding from 1.252 to 0.324 events per patient-year (p = 0.006). In our population of patients with HM3 LVAD, RT reduces bleeding without increasing the incidence of thrombosis. Our retrospective study suggests that an upfront RT strategy in patients with HM3 may be beneficial and should be prospectively studied.
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Affiliation(s)
- Dylan Marshall
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York
| | - Joseph Sanchez
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center - New York Presbyterian, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center - New York Presbyterian, New York, New York
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center - New York Presbyterian, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York.
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Hayashi H, Naka Y, Sanchez J, Takayama H, Kurlansky P, Ning Y, Topkara VK, Yuzefpolskaya M, Colombo PC, Sayer GT, Uriel N, Takeda K. Influence of Atrial Fibrillation on Functional Tricuspid Regurgitation in Patients With HeartMate 3. J Am Heart Assoc 2021; 10:e018334. [PMID: 33412902 PMCID: PMC7955423 DOI: 10.1161/jaha.120.018334] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Functional tricuspid regurgitation (TR) can occur secondary to atrial fibrillation (AF). The impact of AF on functional TR and cardiovascular events is uncertain in patients with left ventricular assist devices. This study aimed to investigate the effect of AF on functional TR and cardiovascular events in patients with a HeartMate 3 left ventricular assist device. Methods and Results We retrospectively reviewed 133 patients who underwent HeartMate 3 implantation at our center between November 2014 and November 2018. We excluded patients who had undergone previous or concomitant tricuspid valve procedures and those whose echocardiographic images were of insufficient quality. The primary end point was death and the presence of a cardiovascular event at 1 year. We defined cardiovascular event as a composite of death, stroke, and hospital readmission due to recurrent heart failure and significant residual TR as vena contracta width ≥3 mm. In total, 110 patients were included in this analysis. Patients were divided into 3 groups: no AF (n=51), paroxysmal AF (n=40), and persistent AF (PeAF) (n=19). Kaplan‐Meier analysis showed that patients with PeAF had the worst survival (no AF 98%, paroxysmal AF 98%, PeAF 84%, log‐rank P=0.038) and event‐free rate (no AF 93%, paroxysmal AF 89%, PeAF 72%, log‐rank P=0.048) at 1 year. Thirty‐one (28%) patients had residual TR 1 month after left ventricular assist device implantation. Patients with residual TR had a significantly poor prognosis compared with those without residual TR (log‐rank P=0.014). Conclusions PeAF was associated with increased mortality, cardiovascular events, and residual TR compared with no AF and paroxysmal AF.
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Affiliation(s)
- Hideyuki Hayashi
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
| | - Joseph Sanchez
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
| | - Yuming Ning
- Department of Surgery Center for Innovation and Outcomes Research Columbia University Medical Center New York NY
| | - Veli K Topkara
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Melana Yuzefpolskaya
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Paolo C Colombo
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Gabriel T Sayer
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Nir Uriel
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Koji Takeda
- Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY
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47
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Nouri SN, Malick W, Masoumi A, Fried JA, Topkara VK, Brener MI, Ahmad Y, Prasad M, Rabbani LE, Takeda K, Karmpaliotis D, Moses JW, Leon MB, Kirtane AJ, Garan AR. Impella percutaneous left ventricular assist device as mechanical circulatory support for cardiogenic shock: A retrospective analysis from a tertiary academic medical center. Catheter Cardiovasc Interv 2020; 99:37-47. [PMID: 33325612 DOI: 10.1002/ccd.29434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/15/2020] [Accepted: 11/30/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS). BACKGROUND Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation. METHODS All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation. RESULTS A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p = .002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p = .049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p = .034 and OR 1.72 [95% CI 1.04-2.86], p = .035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation. CONCLUSIONS Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.
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Affiliation(s)
- Shayan Nabavi Nouri
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Waqas Malick
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amirali Masoumi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Justin A Fried
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Michael I Brener
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Yousif Ahmad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - LeRoy E Rabbani
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Dimitrios Karmpaliotis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Jeffrey W Moses
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Ajay J Kirtane
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - A Reshad Garan
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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48
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Nakagawa S, Takayama H, Takeda K, Topkara VK, Yuill L, Zampetti S, McLaughlin K, Yuzefpolskaya M, Colombo PC, Naka Y, Uriel N, Blinderman CD. Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life. J Pain Symptom Manage 2020; 60:976-983.e1. [PMID: 32464259 DOI: 10.1016/j.jpainsymman.2020.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown. OBJECTIVES To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life. METHODS Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups. RESULTS Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life. CONCLUSION Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.
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Affiliation(s)
- Shunichi Nakagawa
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA.
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Lauren Yuill
- Department of Care Coordination and Social Work, Adult Palliative Care Service, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Suzanne Zampetti
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
| | - Katherine McLaughlin
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig D Blinderman
- Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA
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49
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Griffin JM, DeFilippis EM, Rosenblum H, Topkara VK, Fried JA, Uriel N, Takeda K, Farr MA, Maurer MS, Clerkin KJ. Comparing outcomes for infiltrative and restrictive cardiomyopathies under the new heart transplant allocation system. Clin Transplant 2020; 34:e14109. [PMID: 33048376 DOI: 10.1111/ctr.14109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/07/2020] [Accepted: 10/03/2020] [Indexed: 01/24/2023]
Abstract
The new heart transplantation (HT) allocation policy was introduced on 10/18/2018. Using the UNOS registry, we examined early outcomes following HT for restrictive cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, or cardiac amyloidosis compared to the old system. Those listed who had an event (transplant, death, or waitlist removal) prior to 10/17/2018 were in Era 1, and those listed on or after 10/18/2018 were in Era 2. The primary endpoint was death on the waitlist or delisting due to clinical deterioration. A total of 1232 HT candidates were included, 855 (69.4%) in Era 1 and 377 (30.6%) in Era 2. In Era 2, there was a significant increase in the use of temporary mechanical circulatory support and a reduction in the primary endpoint, (20.9 events per 100 PY (Era 1) vs. 18.6 events per 100 PY (Era 2), OR 1.98, p = .005). Median waitlist time decreased (91 vs. 58 days, p < .001), and transplantation rate increased (119.0 to 204.7 transplants/100 PY for Era 1 vs Era 2). Under the new policy, there has been a decrease in waitlist time and waitlist mortality/delisting due to clinical deterioration, and an increase in transplantation rates for patients with infiltrative, hypertrophic, and restrictive cardiomyopathies without any effect on post-transplant 6-month survival.
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Affiliation(s)
- Jan M Griffin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Ersilia M DeFilippis
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Hannah Rosenblum
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Justin A Fried
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Maryjane A Farr
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Mathew S Maurer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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50
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Hayashi H, Naka Y, Sanchez J, Takayama H, Kurlansky P, Ning Y, Topkara VK, Yuzefpolskaya M, Colombo PC, Sayer GT, Uriel N, Takeda K. Consequences of functional mitral regurgitation and atrial fibrillation in patients with left ventricular assist devices. J Heart Lung Transplant 2020; 39:1398-1407. [PMID: 32994093 DOI: 10.1016/j.healun.2020.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 08/15/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (MR) (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. This study aimed to investigate the characteristics and prognostic significance of FMR and AF in patients with LVADs. METHODS We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We defined significant FMR as the ratio of MR color jet area to left atrial area of >20% and persistent or permanent AF (PeAF) as persistent or permanent AF at LVAD implantation. RESULTS A total of 380 patients were included in this analysis. Patients were divided into 6 groups: patients with no PeAF and no significant FMR (Group 1), patients with no PeAF but with significant FMR (Group 2), patients with PeAF but no significant FMR (Group 3), patients with PeAF and significant FMR (Group 4), patients with concomitant mitral valve surgery (MVS) at LVAD implantation and without PeAF (Group 5), and patients with concomitant MVS and with PeAF (Group 6). A total of 56 patients (15%) died within 2 years. Kaplan-Meier curve analysis demonstrated a 2-year survival of 81% in Group 1, 89% in Group 2, 87% in Group 3, 47% in Group 4, 87% in Group 5, and 79 % in Group 6 (log-rank test, p < 0.001). The multivariable Cox proportional-hazards model showed that classification in Group 4 was an independent predictor of mortality (hazard ratio, 4.31; 95% CI: 2.19-8.46; p < 0.001). CONCLUSIONS The coexistence of significant FMR and PeAF may represent a poor prognostic marker in patients undergoing LVAD implantation.
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Affiliation(s)
| | | | | | | | | | - Yuming Ning
- Center for Innovation and Outcomes Research, Department of Surgery
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
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